A guide for health professionals working with
immigrant and refugee children and youth

Oral Health Screening

Key points

  • Oral health and dental care are unmet needs of young newcomers to Canada.
  • Refugee children may have never received oral health care or been exposed to preventive measures (e.g., a toothbrush, fluoridated toothpaste or water).
  • Dental caries in newcomer children can lead to complications: pain, problems with feeding, growth and learning, and damage to permanent teeth.

Oral health is a basic component of children’s health,1 and a particular concern in young newcomers to Canada. Newcomer status is itself a risk factor for early childhood caries (ECC),1 and young newcomers may not have received dental care before their arrival or learned about oral hygiene in their country of origin.

Complications of early childhood caries:2

  • Pain
  • Difficulty chewing, which can  lead to poor feeding and slow weight gain
  • Difficulty speaking
  • Oral infections
  • Loss of sleep, difficulty concentrating and interrupted learning
  • Decay and loss of teeth
  • Damage to permanent teeth
  • Increased risk of caries development
  • Increased risk of chronic inflammation and abscess formation

Because newcomers to Canada are more likely to first seek primary health care before dental care, paediatricians, physicians and other health care providers play an important role in screening and referral for dental care.3

Epidemiology

Many Canadian children have poor oral health: 57% of 6 to 11 year-olds and 59% of 12 to19 year-olds have (or have had) a cavity.4 However, the burden of illness disproportionately affects young newcomers, both in terms of oral health status and use of dental services.1

Canadian data are limited, but U.S. and global data provide considerable insight on the state of oral health in young newcomers:5,6

  • One U.S. study of 366 refugee children found that 45% had dental caries, with the highest rates in children from Bhutan (50%), Burma (48%), Thailand (50%) and Malaysia (45%).
  • Another study of 224 refugee children reported that 80% of children from Eastern Europe and 40% from Africa had experienced caries.
  • Refugees have been found to have a higher rate of untreated decay than U.S.-born children (49% vs. 23%, respectively), despite having similar caries rates.

Figure 1: Dental caries levels in 12-year-olds worldwide

Figure 1: Dental caries levels in 12-year-olds worldwide

Source: Reproduced, with the permission of the publisher, from The World Oral Health Report 2003: The approach of the WHO Global Oral Health Program (Fig. 5, Page 11, accessed 14 January 2014).

Risk factors                                         

A number of risk factors for early childhood caries are particularly relevant to young newcomers:1,7

  • New immigrant status
  • Lower income or parental education level
  • Lack of a family dentist or of access to dental insurance or coverage
  • Breastfeeding at frequent intervals
  • Frequency snacking during the day
  • A previous history of caries, plaques or demineralization
  • Little or no exposure to fluoride

Screening and intervention

Young newcomers, especially refugees, may never have practiced oral health care (e.g., toothbrushing, fluoridated toothpaste or water) or received it from a dental professional before arriving in Canada.

The Canadian Collaboration for Immigrant and Refugee Health (CCIRH) have noted that, because physicians are often the first point of contact in the health care system for newcomers, they can play a key role in ensuring oral health through screening and referral.3 Their recommendations are summarized in Table 1.

Table 1: Assessing oral health in young newcomers to Canada

Screen for early signs of caries or obvious cavities and pain

  • Screen all newcomer preschool and school-aged children for early signs of dental caries, e.g., demineralized white spots or obvious cavities and pain. See Figures 2-4, below.
  • Screen for dental pain
    • Recommend nonsteroidal anti-inflammatory medications (if not contraindicated) for tooth pain with or without localized swelling when dental therapy cannot be started immediately. Refer patient to a dentist.
    • Consider antibiotic treatment only if signs of infection (e.g., swelling, redness, pain) suggestive of a dental abscess are present.
Refer patients
  • Refer patients with obvious dental disease to a paediatric or family dentist.
  • Provide an active referral to a dentist rather than a passive or verbal recommendation (to increase the likelihood of follow-through by patients).
  • Ensure children have a ‘dental home’ by age 1 year.

Application of fluoride varnish (by trained provider)

  • Consider application (or referral for application) of fluoride varnish to teeth of children at high risk for caries
Recommend teeth brushing
  • Recommend teeth brushing twice daily with toothpaste (as per age-appropriate guidelines)
Screen early feeding and later eating practices
  • Screen for high risk feeding habits and counsel caregivers against these:
    • Infants: frequent nighttime feedings, bottle/sippy cup in bed, addition of sugar or honey to feeds or pacifiers
    • Young children: bottle/sippy cup in bed, frequent snacking or milk bottles, sugar-containing drinks

Sources: McNally M, Matthews D, Pottie K, for the CCIRH. Evidence-based clinical guidelines for immigrants and refugees. Appendix 16: Dental disease; Evidence review for newly arriving immigrants and refugees. CMAJ 2011;183(12):E824-925; Rowan-Legg A; CPS, Community Paediatrics Committee. Oral health care for children – a call for action. Paediatrics & Child Health 2013;18(1):37-43.

Figure 2. White spot lesions

Figure 2. White spot lesions

Source for Figures 2-5: Travis Nelson, DDS, MSD, MPH. Department of Pediatric Dentistry University of Washington. With permission.

Figure 3. Mild dental disease

Figure 3. Mild dental disease

Figure 4. Moderate dental disease

Figure 4. Moderate dental disease

Figure 5.  Severe dental disease

Figure 5.  Severe dental disease

All health providers can encourage and reinforce good oral health practices with newcomer families they see, by sharing these messages:

  • Don’t put your baby or toddler to bed with a bottle or sippy cup – at night or at naptime.
  • Minimize sugary foods and liquids (including juice and milk). A child doesn’t need to carry a bottle around between feedings.
  • Teach children to drink from an open cup near first birthday.
  • Never ‘sweeten’ a child’s a pacifier (soother) by dipping it in sugar or honey
  • Don’t clean your child’s soother (or anything else she puts in her mouth) by putting it in your own mouth:  this can pass bacteria or viruses from mother to child

Information, educational materials and practice tools can be found on the Protecting All Children’s Teeth (PACT) Program website of the American Academy of Pediatrics.

Access to care

Dental care is not covered under the Canada Health Act, and lack of insurance coverage can be a barrier to accessing dental care for newcomer families.7,8 One  study found that lack of dental care and insurance were the strongest predictors of caries in children younger than 7 years of age.7

Government funding for dental services for which young newcomers to Canada may be eligible is summarized below.  Publicly funded dental services tend to have a lower reimbursement scale than private coverage. Discrepancies between public and private reimbursement rates can lead to public patients not being accepted as readily by dentists.9

Federal dental coverage: The Interim Federal Health Program

Refugees and refugee claimants may be eligible for limited dental services under the Interim Federal Health Program. Program details can be found in the Health Insurance for Immigrant and Refugee Families section of this resource and on the Government of Canada website.

Provincial/territorial dental programs

Young newcomers to Canada may be eligible for dental funding assistance through a number of provincial or territorial programs,1 as summarized in Table 2.  Many of these programs depend on the child having provincial/territorial health coverage, which may not include all newcomers, and refugee claimants in particular.

Program Eligibility Services covered

Table 2: Publicly funded dental programs for children

British Columbia    
Healthy Kids Children and youth 0 –19 yrs from low-income families in receipt of premium assistance through Medical Services Plan
  • $1400/two years of basic dental services.
  • $1000/year toward general anesthesia fees (hospital or private facility)
  • Emergency treatment for pain relief (beyond $1400 limit)
  • No orthodontic

Dental Benefits Program for Children and Youth in Foster Care

Children and youth in foster care covered up to $700/year

  • Basic, emergency and orthodontic care
Alberta    
Alberta Child Health Benefit Children and youth zero – 18 years of age from low-income families Basic coverage: dental exams, cleaning, X-rays, fillings and extractions
Family Support for Children with Disabilities Children and youth zero – 18 years of age with a disability
  • Basic dental treatment, with some orthodontic care (directly related to child’s disability and approved by a dental review committee)
    • Covers portion of costs exceeding that covered by guardian’s dental insurance plan OR if guardian does not have dental insurance, costs exceeding $250 annually
Foster Care Children and youth zero – 18 years of age in foster care Basic coverage: dental exams, cleaning, X-rays, fillings and extractions
Assured Income for the Severely Handicapped (AISH) Children of parents with a disability who are unable to work Basic coverage: dental exams, cleaning, X-rays, fillings and extractions
Saskatchewan    
Family Health Benefits Children zero – 18 years from low-income families

Basic coverage

Supplementary Health Program Foster children

Diagnostic, preventive, restorative, oral surgery

Public Health Services Dental Clinic (Saskatoon Health Region)

Children zero – 16 years who have limited or no dental coverage

Preventive and treatment services

Manitoba    
Health Services Dental Program Children <18 years of age who have a disability or are wards of the state covered up to $500/year Basic diagnostic, preventive, restorative, endodontic, periodontal, prosthodontic, oral surgery services

SMILE plus program (Winnipeg Regional Health Authority)

At-risk children in the Winnipeg region Preventive and basic treatment services
Healthy Smile Happy  Child intersectoral partnership

At-risk infants and preschool children and their families

Oral health promotion using community development approaches

Free First Visit Program (Manitoba Dental Association)

Children <36 months of age

Early dental screenings

Ontario    
Healthy Smiles

Children 17 years and under from low-income households; and children receiving benefits through
the Ontario Disability Support Program, Temporary Care Assistance, Assistance for Children with Severe
Disabilities, and Ontario Works (in some cases) 

Preventive and basic treatment services

Quebec    
Régie de l’assurance maladie du Québec: Children’s Dental Care Program

All children <10 years of age

  • Basic diagnostic, restorative and oral surgery
    • Does not include cleaning or fluoride application

Children from low-income families

  • Basic diagnostic, restorative and oral surgery
    • >12 years of age: annual teeth cleaning
    • 12–15 years: annual fluoride application
New Brunswick    
Healthy Smiles, Clear Vision Children <18 years of age from low-income families
  • Examination, basic diagnostic, extractions and some preventive treatment
    • Up to a maximum of $1000/year
Nova Scotia    
MSI Children’s Oral Health Program

Children <14 yrs of age

  • Families required to access private coverage first
  • Diagnostic (dental exam), preventive (one sealant application), and treatment services (fillings, fluoride application in some cases)
    • General anesthesia covered in hospital settings only
Mentally Challenged Program
  • Children with disability (no age limit)
  • Required to access private coverage first
  • Diagnostic, preventive, and treatment services
    • General anesthesia covered in hospital settings only
Prince Edward Island    

Children’s Dental Care Program (Treatment Services)

  • Children three – 17 years of age
  • Annual registration fee of $15/child to a maximum of $35/family (waived for low- income families)
  • Parent pays 20% of treatment cost, unless annual income <$30,000/year

Diagnostic and basic treatment services

Children’s Dental Care Program (Prevention) All school-aged children 3 – 17 years of age Oral health education, screening, scaling, topical fluoride, sealants
Pediatric Specialist Services Dental Program
  • Children in medical and financial need
  • Annual registration fee of $15/child
  • Diagnostic, treatment and some preventive services
  • Preventive orthodontic clinic
  • Directed at children in low-income families
  • Minor preventive orthodontic services
Early Childhood Dental Initiative 15- and 18-month-old babies at Public Health immunization clinics

Screening, risk assessment by dental hygienists

Newfoundland    
Children’s Dental Health Program
  • All children 0–12 years of age
  • Families required to access private coverage first
  • Youth 13–17 years of age in low-income families or on social assistance
  • Children’s component: diagnostic, preventive periodontal, restorative services (i.e., exams, cleanings, fillings, fluoride application, extractations, sealants)
  • Social assistance component: exams, fillings, extractions and emergency treatment
Nunavut and the Northwest Territories    
Non-Insured Health Benefits Program

Registered First Nations and Inuit

Emergency, diagnostic, restorative, endodontic, periodontal, prosthodontic, oral surgery, orthodontic services
Yukon Territory    
Children’s Dental Health Program (Yukon Health and Social Services)

Two programs:

  • Preschool children
  • All school-aged children from kindergarten to Grade 8 (or Grade 12) depending on the place of residence
  • Preventive, restorative, periodontal, and oral surgery services
  • Emergency (accidental) not covered in school-aged children’s plan

Sources:  Adapted from Rowan-Legg A; CPS, Community Paediatrics Committee. Oral health care for children – a call for action. Paediatr Child Health 2013;18(1):37-43; Canadian Institute for Health Information. Treatment of preventable dental cavities in preschoolers: A focus on day surgery under general anesthesia. Appendix B:21-3.

 

Other barriers

More information on how to recognize and address potential barriers to health care in newcomer patient and on using interpreters can be found on this website.

Selected resources

References

  1. Rowan-Legg A; CPS, Community Paediatrics Committee. Oral health care for children – a call for action. Paediatrics & Child Health 2013;18(1):37-43.
  2. American Academy of Paediatrics. Oral Health and Protecting All Children’s Teeth Curriculum (PACT)
  3. McNally M, Matthews D, Pottie K, for the Canadian Collaboration for Immigrant and Refugee Health. Evidence-based clinical guidelines for immigrants and refugees. Appendix 16: Dental disease; Evidence review for newly arriving immigrants and refugees. CMAJ 2011;183(12):E824-925.
  4. Health Canada. Summary report on the findings of the oral health component of the Canadian Health Measures Survey 2007–2009. Ottawa, Ont.: Health Canada, 2010.
  5. Cote S, Geltman P, Nunn M, et al. Dental caries of refugee children compared with U.S. children. Pediatrics 2014; 114(6):e733-40.
  6. Shah A, Mitchell T, Oladele A. Nutritional status of refugee children entering DeKalb County, Georgia. J Immigrant Minority Health 2013 Jul 5 [Epub ahead of print].
  7. Werneck RI, Lawrence HP, Kulkarni GV, et al. Early childhood caries and access to dental care among children of Portuguese-speaking immigrants in the city of Toronto. J Can Dent Assn 2008;74(9):805.
  8. Newbold KB, Patel A. Use of dental services by immigrant Canadians. JCDA 2006;72:143a-f.
  9. Bisgaier J, Cutts DB, Edelstein BL, et al. Disparities in child access to emergency care for acute oral injury. Pediatrics 2011;127(6):e1428-35.

Editor(s)

  • Andrea Hunter, MD
     

Last updated: September, 2016

Also available at: http://www.kidsnewtocanada.ca/screening/oral-health
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Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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